National Guidelines for Methods of Preventing Disease – summary

The Swedish National Board of Health and Welfare’s National Guidelines for Methods of Preventing Disease provide recommendations for methods of preventing disease by supporting patients in their efforts to change an unhealthy lifestyle habit.

The lifestyle habits that the guidelines discuss are

tobacco use

hazardous use of alcohol

insufficient physical activity

unhealthy eating habits

These lifestyle habits are also among the risk factors that WHO stresses in its European Strategy for the Prevention and Control of Non-communicable Diseases. According to WHO, healthy lifestyle habits can prevent 90 per cent of all diabetes, 80 per cent of all myocardial infarcts and 30 per cent of all cancer. People who refrain from smoking, eat healthily, engage in moderate physical activity and consume moderate quantities of alcohol live an average of 14 years longer than those with unhealthy lifestyle habits.

Although these lifestyle habits cause so much disease while methods for the prevention of disease constitute part of the task of the healthcare system under the Health and Medical Service Act (Swedish Code of Statutes 1982:763), efforts to prevent disease still do not occupy an undisputed place in the system. There is no uniform clinical practice, and there are large variations among regions, as well as among hospitals and clinics.

Task of the Swedish National Board of Health and Welfare

The Swedish National Board of Health and Welfare has been tasked with drawing up evidence-based national guidelines for proper care of the most widespread diseases and of patients with other serious diseases whose care consumes major resources.

The national guidelines of the Swedish National Board of Health and Welfare offer support for control and management in the healthcare system. The objective is to promote the efficient use of healthcare resources, as well as their allocation on the basis of need and their management on the basis of systematic and transparent priorities. Thus, the primary target groups of the guidelines are healthcare decision makers (elected officials, senior civil servants and hospital administrators), as well as healthcare professionals.

The Swedish National Board of Health and Welfare engages a large number of experts with scientific and clinical experience when drawing up its national guidelines. The effort begins with a review of the current state of research in the area concerned. The guidelines are to be based on the best available knowledge and proceed first and foremost from systematic reviews. The scientific evidence is reviewed, assessed and presented in accordance with predetermined criteria.

The priorities that the Swedish National Board of Health and Welfare proposes are based on the national model for priorities. Priorities in accordance with the model proceed from a total appraisal of three dimensions:

severity of the condition

efficacy of the method

cost-effectiveness

Methods based on advice or counselling

The basis for all methods in the National Guidelines for Methods of Preventing Disease is some form of advice or counselling. The methods have been assigned to three possible levels – brief advice, counselling and advanced counselling. The breakdown proceeds from a number of considerations – such as the structure, content and scope of the methods – based on how they have been described in the scientific literature.

The levels are the same for all four lifestyle habits but may differ in terms of scope, as well as the tools and devices that are included. All levels presume that

healthcare professionals are knowledgeable about the lifestyle habit(s) that the method concerns

the healthcare system has already determined that the person has unhealthy lifestyle habits.

All other methods in the guidelines – such as nicotine medications or exercise on prescription – are adjuncts to some form of advice or counselling.

Table 1. Swedish National Board of Health and Welfare’s three levels of methods for preventing disease.

Level

Description

Amount of time

Lifestyle habit

Brief advice

Information and short advice and recommendations about lifestyle habits (not the same thing as asking questions about lifestyle habits).

Possible addition of written information.

Usually less than 5 minutes.

Counselling

Dialogue between healthcare professional and patient.

Adaptation to the specific person’s age, health, risk levels, etc.

Possible addition of various tools and devices, as well as special follow-up.

Usually 10–15 minutes, occasionally up to 30 minutes.

Hazardous use of alcohol

Insufficient physical activity

Advanced Counselling

Dialogue between healthcare professional and patient.

Adaptation to the specific person’s age, health, risk levels, etc.

Possible addition of various tools and devices, as well as special follow-up.

Ordinarily theory-based or structured, such as

Social learning theory/Social cognitive theory

Health belief model

Theory of planned behaviour

Stages of change/Trans-theoretical model

Motivational interviewing (MI)

Cognitive behavioural therapy (CBT)

Method with components from more than one theory.

Healthcare professionals with training in the method used.

Often longer than counselling

Smoking

Unhealthy eating habits

Recommendations

Smoking

The healthcare system should offer advanced counselling to patients who smoke. Methods to help patients quite smoking are presumably common already, but the Swedish National Board of Health and Welfare believes that the recommendations raise the ambition level and thereby increase the associated healthcare costs.

Smoking refers to daily smoking, regardless of the number of cigarettes. More sporadic smoking is also included for people who are pregnant, breastfeeding or facing surgery; they are subject to special recommendations.

Hazardous use of alcohol

The healthcare system should offer counselling to patients with hazardous use of alcohol. In primary care, the recommendation of counselling chiefly requires knowledge and awareness of hazardous use, whereas other areas of health care presumably require more knowledge and additional resources to provide the method.

Hazardous use of alcohol refers either to high average consumption or binge drinking at least once a month. High average consumption exceeds 14 standard glasses per week for men and 9 standard glasses for women. binge drinking is defined as five or more standard glasses on the same occasion for men and four or more standard glasses for women. A standard glass corresponds to 33 cl of beer, 12–15 cl of wine or just under 4 cl of hard liquor.

Insufficient physical activity

The healthcare system should offer counselling with the adjunct of exercise on prescription or a pedometer, as well as special follow-up, to patients with insufficient physical activity. The Swedish National Board of Health and Welfare believes that the healthcare system is making an effort in the area, but that there are large variations throughout the country. Additional resources are probably needed to comply with the recommendation.

Insufficient physical activity refers to total physical activity of less than 30 minutes per day.

Unhealthy eating habits

The healthcare system should offer advanced counselling to patients with unhealthy eating habits. Eating habits are probably the lifestyle habit to which the healthcare system currently devotes the fewest resources, which presumably can lead to significant cost increases in the area.

Unhealthy eating habits refer to patients who score low on a dietary index that the Swedish National Board of Health and Welfare developed during its work on the guidelines. The index is based on consumption of fruit, vegetables, fish and lownutrition food (such as sweets, chips, buns and cakes, and soft drinks). Proceeding from this definition, approximately 20 per cent of the population has unhealthy eating habits.

Major initiative for the healthcare system

The Swedish National Board of Health and Welfare believes that, taken as a whole, the recommendations will increase healthcare costs due to the time that professionals will need to set aside. Another large share of the cost increase will be for skills development and advanced training. The healthcare system may have to put together a general training programme to increase knowledge and influence attitudes about methods of preventing disease, as well as a special training programme that offers in-depth information about lifestyle habits and the recommended methods.

Because the government wants to strengthen the efforts of the healthcare system to prevent disease, it has decided to provide special support for adoption of these national guidelines. The support is intended both for care providers and for healthcare professionals.

Health-promoting attitude during counselling about lifestyle habits

The Swedish National Board of Health and Welfare stresses how important it is that healthcare professionals exhibit a health-promoting attitude when implementing the guidelines. The primary role of healthcare professionals during an counselling about lifestyle habits is to provide patients with knowledge, tools and support for improving their health. A counselling should be structured as a supportive dialogue that proceeds from the patient’s own experience of the lifestyle habit and that takes the patient’s motivation for change into consideration. Such an approach strengthens the patient’s sense of empowerment and offers the patient a central role in improving their health. This kind of health-promoting attitude is important in all healthcare situations, but it is particularly important when the treatment involves a change in lifestyle habits – in other words, altering daily routines and ingrained behaviour patterns.

Deciding when to ask

According to the Health and Medical Service Act, the healthcare system shall strive to prevent ill-health. Anybody who contacts the healthcare system should, when appropriate, be offered information and methods for preventing disease or injury. The Swedish National Board of Health and Welfare feels that the healthcare system should pay more attention to the lifestyle habits of patients than it currently does. Thus, all healthcare professionals should have the tools they need to ask questions, offer methods of prevention or refer the patient to someone with more expertise.

As with diagnostics and treatment in general unhealthy lifestyle habits should be identified in a manner that feels relevant to the patient. Healthcare professionals must always perform an individual assessment of when and how to ask questions so that they can do so in the best possible way while being sensitive to each patient’s expectations and values.

Indicators for monitoring

The Swedish National Board of Health and Welfare has been tasked by the government to submit regular reports concerning the performance of the healthcare system. The Board has also been tasked to monitor how the national guidelines are used and how they affect clinical practice.

Thus, the Board develops indicators as part of the effort to draw up national guidelines. The indicators are measurements intended to reflect quality. They are to be usable as data for monitoring and improving care, as well as for open reporting of the healthcare system’s structures, processes, performance and costs.

A comprehensive, nuanced view of quality in the healthcare system is vital to a number of stakeholders: the general population, patients, family members, healthcare professionals, managers, the political and administrative management of healthcare principals, and the government.

One current problem for these guidelines is the lack of data sources for ongoing national monitoring of the indicators, although the situation may be different at the local and regional level. The Swedish National Board of Health and Welfare will develop codes directly adapted to the guidelines in order to facilitate uniform documentation, and will take other measures that support implementation of the guidelines and the ongoing development effort required to enable monitoring.